- In coronary artery bypass surgery, you have performed tens of thousands of procedures,
and you have a particular interest in off-pump coronary artery bypass graft surgery, which
is a surgery on a beating heart. Dr. Anton Titov MD
It's more demanding from the surgeon, technically, but at the same time, it has certain advantages
for patients.
Please compare risks and benefits of off-pump coronary artery bypass graft surgery and on-pump,
the classical technique, and tell us about your experience with this advanced technique
of coronary artery bypass grafting.
- Well, the off-pump surgery was introduced in the 1990s in South America and came to
developed countries in North America and Europe with the so-called MIDCAB operation, which
is a small incision on the lateral chest to do a revascularization of the left anterior
descending artery.
And from this procedure, the so-called OPCAB procedure, off-pump coronary artery beating
heart procedure, was developed where you can graft all three vessels on the beating heart.
The advantage is that you don't need - as "off-pump" name says, you don't need the heart-lung
machine.
For using the heart-lung machine, you have to cannulate the aorta.
This may lead to a dislodgement of debris of aortic plaque, which may lead to embolism,
which may, this may lead to a cerebral infraction.
So, in the SYNTAX study where coronary artery patients were analyzed, the stroke rate was
2.2%.
But if you're using the off-pump technique with the so-called T-graft, where you implant
the LIMA to the LAD, and then a second graft into the LIMA with the so-called aortic no-touch
technique, where you don't perform an aortic anastomosis.
You have no, absolutely no cerebral infraction which is generated by the surgery.
It's a huge deal - to decrease the risk of stroke, and we'll talk about that in a second,
it is a very big deal!
- Yes!
The other thing, which I'm doing to generate this goal is I'm always resecting the left
atrium, because 90% of embolism from the left heart comes from the left atrium.
Because in atrial fibrillation, we have a thrombus formation.
When the patient gets back into the sinus rhythm, the thrombus is ejected and you have
embolism [stroke] And when you resect the left atrium, you're eliminating this risk
as well.
So, this is another point.
No aortic touch, resection of the left atrium, and then you have two major risk factors eliminated,
which may lead to cerebral strokes and other neurological complications.
So, the off-pump procedure has many advantages not only related to a neurologic outcome.
It can be done in patients with major deficiencies, with, for example, with renal disease, with
pulmonary disease.
The avoidance of the heart-lung machine leads to a substantial advantage, and this has been
proven by literature.
And, of course, you need an experienced surgeon, and the surgical technique has to be adequate.
But we have several tools nowadays.
We are measuring the graft flow, the patency and the flow, and you can exactly say this
graft is patent.
The literature says 10 to 15% of the coronary artery anastomosis have technical defects,
and you can detect those immediately, not later in the intensive care via ECG or enzymes.
So, this is a big step towards patient safety.
Then, of course, an OPCAB surgery always maintains the blood pressure.
You have the running ECG.
You have the contracting heart.
These are also parameters to tell you that you're on the safe side, that your anastomosis
is technically adequate, and the patient is going to do well in the long run.
- So, you have a feedback from the patient's body, from the heart, during that duration,
which is also a significant advantage.
- That's exactly the point.
And the patients, they wake up in the same condition after appendectomy, you know.
After heart-lung machine, if patients are sent into a CT scan and doctors see a cerebral
edema which lasts for some period of time.
You have mental deficiencies caused by the heart-lung machine.
All these detrimental factors, you don't have with OPCAB surgery, so it's a big step ahead.
Off-pump CABG has major advantages for severely ill patients, for patients with neurological
deficits.
Those are the advantages where they profit very much from OPCAB surgery.
- But the key factor, of course, is surgeon as the most important prognostic factor for
the patient,
- And then, the patient-related risk factors, of course.
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